One-Year Follow-Up after Multimodal Prehabilitation Interventions in Radical Cystectomy.

Multimodal prehabilitation is the process of enhancing physiological, nutritional, and psychological resilience to increase patients' functional capacity before major cancer surgery and aims to empower the patient to withstand the pending stress of major surgery and ultimately to improve long-term outcomes. The effect of physical prehabilitation to counteract the physical decline in surgical cancer patients has been documented; however, long-term results have not yet been published. This follow-up study aims to evaluate 1-year results on the efficacy of physical prehabilitation after bladder cancer surgery. The efficacy of prehabilitation was measured over the course of 1 year in 107 patients randomized to (1) pre- and rehabilitation or (2) standard care divided by n = 50 in the intervention (I) and n = 57 in the standard group (S). Physical function was measured by muscle leg power, and nutritional status was expressed with handgrip strength. Prehabilitation in major bladder cancer surgery can significantly improve physical function with 19.8 Watt/kg (p = 0.04), lean body mass (p = 0.047) and body cell mass (p = 0.03), and regained nutritional status one year after surgery. The results demonstrate that the restoration of physical function is vital to a full recovery.

The use of digital technologies to support home-based prehabilitation prior to major surgery: A systematic review.

BACKGROUND: Prehabilitation is a multidimensional and multidisciplinary approach, to prepare patients for surgery, with the aim of improving postoperative outcomes. Worldwide, healthcare systems are facing challenges with a gap between demand and supply of healthcare services. Telehealth is seen as a solution for delivering sustainable and efficient treatments. The effect of providing prehabilitation using telehealth solutions is unclear. OBJECTIVE: This systematic review investigated the existing literature regarding the effects and feasibility of technologies for remotely supporting home-based prehabilitation compared to standard care on pre- and postoperative outcomes in adults undergoing elective major surgery. METHODS: A literature search identified relevant studies published between 1 January 2012 and December 2022 in PubMed, PsychInfo, Cinahl and the Cochrane Library. We included RCTs, feasibility and pilot studies. The quality of studies was evaluated using Cochrane's Risk of bias assessment and by narratively rating the certainty of evidence. RESULTS: Six randomized controlled trials and 20 pilot/feasibility studies were included. The number and content of the interventions varied, depending on context and resources. Multiple approaches in the use of digital healthcare solutions were applied and the results highlight the potential of providing health services remotely. CONCLUSION: The use of technologies to support remote home-based prehabilitation in patients undergoing elective major surgery is feasible and has high acceptability, though telehealth is a broad term and wide-ranging strategies are used. Digital technologies for supporting home-based prehabilitation are likely to play an essential role in future health care as resources are scarce and innovative solutions are needed.

DaPeCa-7: comparative assessment of fluorodeoxyglucose positron emission tomography/computed tomography (CT) and conventional diagnostic CT in diagnosis of lymph node metastases, distant metastases and incidental findings in patients with invasive penile cancer.

OBJECTIVES: To evaluate diagnostic accuracy of 18 F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) compared to contrast-enhanced CT in assessment of inguinal lymph node (ILN) metastases, distant metastases and synchronous cancers in patients with penile squamous cell carcinoma (pSCC). PATIENTS AND METHODS: During a 4-year period, patients with pSCC were scheduled for FDG PET/CT prior to surgical treatment at two referral centres that manage all penile cancers in Denmark. The primary endpoint was diagnostic accuracy of FDG PET/CT and of CT alone with histopathology or Response Evaluation Criteria In Solid Tumors (RECIST) as reference. RESULTS: We evaluated 171 patients for distant metastases and synchronous incident cancers and examined 286 groins in 143 patients for LN metastases by FDG PET/CT. Six groins disclosed false negatives. FDG PET/CT sensitivity was 85.4% per patient. In 135 patients (270 groins), CT images were evaluated separately and 22 groins disclosed false negatives. CT sensitivity was 47.5% per patient. FDG PET/CT detected pSCC distant metastases in seven patients. Distant metastases from other cancers were newly detected in three patients. In eight patients, an incidental synchronous cancer was detected. Seven out of the 18 distant malignancies detected depended on FDG PET information. CONCLUSION: This study underlines the increased diagnostic accuracy of FDG PET/CT compared to CT alone in the evaluation of ILN status. In patients with palpable LNs, the advantage of FDG PET/CT over CT is less pronounced. FDG PET/CT may play a role in penile cancer evaluation.

Progress towards a Nordic standard for the investigation of hematuria: 2019.

Objective: To describe the management of patients with hematuria in the Nordic countries in relation to bladder cancer epidemiology, especially in the context of introducing fast track pathways with the aim of proposing a common guideline. Materials and methods: Epidemiological data on bladder cancer from each country, and the combined cancer registry, Nordcan, were analyzed. The evolution of the different national recommendations and the introduction of fast track pathways were assessed. Patients' demographics, type of hematuria and cancer detection rates were analysed if available. Results: The crude incidence of bladder cancer has increased substantially since the 1960s, while the age standardized incidence has been stable during recent decades. The relative survival has increased in all countries, while the mortality has been stable. For those with microscopic hematuria there has been a clear trend towards less rigorous investigations. In the fast track pathways, introduced in three of five countries, about one in five patients with macroscopic hematuria had a cancer diagnosis. Data show that time to diagnosis has been reduced. Conclusions: The number of patients with bladder cancer is increasing in the Nordic region. The introduction of fast track pathways has been important in improving the management of patients with suspicion of the disease. Our recommendation is to focus on macroscopic hematuria in the fast track pathways. Microhematuria without any symptoms should not be an indication for cystoscopy. However, urinary tract symptoms accompanied by microhematuria can still be investigated according to respective guidelines but not necessarily within fast track pathways.

Detection of Lymph Node Metastasis in Patients with Bladder Cancer using Maximum Standardised Uptake Value and 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography: Results from a High-volume Centre Including Long-term Follow-up.

BACKGROUND: Preoperative staging with 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) combined with computed tomography (CT) is used for the evaluation of metastatic disease in patients with invasive bladder cancer. The use of quantification with maximum standardized uptake value (SUVmax) of regional lymph nodes (LNs) has been suggested to increase the diagnostic ability for detection of malignancy. OBJECTIVE: Assessment of the utility and clinical relevance of SUVmax in 18F-FDG PET in detecting regional nodal metastases in patients considered for radical cystectomy. DESIGN, SETTING, AND PARTICIPANTS: From 2011 to 2014, we identified a total of 119 patients with urothelial carcinoma who underwent radical cystectomy with extended LN dissection; additionally, 12 patients were identified by preoperative biopsy. All patients underwent 18F-FDG PET/CT before treatment recommendation. Pathological findings were compared with preoperative PET/CT staging and analysed in a regional- or patient-based model according to SUVmax values. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: In total, 2291 LNs were identified in 131 patients; locoregional involvement of 85 LNs were confirmed in 34 patients. RESULTS AND LIMITATIONS: SUVmax >2 analysis: sensitivity±95% confidence interval of 79.4% (62.1-91.3) and specificity 66.5% (55.7-75.3). SUVmax >4 based analysis: sensitivity was 61.8% (43.6-77.8) and specificity was 84.5% (75.8-91.1). Two years of follow-up implied that higher SUVmax is correlated with higher recurrence risk, independent of conventional pathological findings. CONCLUSIONS: 18F-FDG PET/CT using SUVmax of LNs is a useful tool for preoperative evaluation of pelvic LN metastases from invasive bladder cancer and contributes to the selection of patients for personalized treatment. PATIENT SUMMARY: In this report, we establish that it is possible to identify disease from bladder cancer in the lymphatic tissue surrounding the bladder using a scan analysis. This assists in the selection of treatment for patients with bladder cancer and may spare patients from unnecessary procedures.

Validation of the Clavien-Dindo Grading System in Urology by the European Association of Urology Guidelines Ad Hoc Panel.

CONTEXT: Since 2012 uniformed reporting of complications after urological procedures has been advocated by the European Association of Urology (EAU) guidelines. The Clavien-Dindo grading system was recommended to report the outcomes of urologic procedures. OBJECTIVE: To validate the Clavien-Dindo grading system in urology. DESIGN, SETTING, AND PARTICIPANTS: Members of the EAU working group compiled a list of case scenarios including those with minor and major complications. A survey was administered online via Survey Monkey to the members of EAU committees for the appropriate grading according to the Clavien-Dindo classification of surgical complications. Scenarios with intraoperative complications were intentionally included to assess respondents' awareness of the Clavien-Dindo applicability. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Survey data collected were used to calculate agreement rates and to estimate the overall inter-rater agreement on all cases using Fleiss' kappa (κ). Differences in agreement rates for each scenario among groups with different criteria about the system were estimated using the chi-square test. RESULTS AND LIMITATIONS: Evaluable responses were received from 81 out of 174 invited raters (46.5%). Of them 56.9% believed that the Clavien-Dindo system was adequate for grading postoperative complications. The agreement rate was over a score of ≥80% in nine cases, 60-79% in 10 cases, 40-59% in 14 cases, and <40% in two cases. Interestingly, the agreement rate on the nonapplicability of the Clavien-Dindo system was quite low, ranging from 27.5% to 67.2% (κ=0.147). Being a resident rather than a specialist affected only the distribution of agreement rates in case 1 (ie, score IIIb: 83.3% vs 94.1%). Being an academic or having affiliation did not have any impact on the distribution of agreement rates in all cases but one. CONCLUSIONS: The Clavien-Dindo classification is a standardised approach to grade and report postoperative complications in urology and should be used systematically. However, it does not apply for intraoperative complications, and there is a need for an additional tool. PATIENT SUMMARY: A rigorous methodology is mandatory when surgeons report about complications after surgery. In this study, the European Association of Urology Guidelines Panel has validated the use of the Clavien-Dindo grading system in urology.

Quality assessment of partial nephrectomy complications reporting using EAU standardised quality criteria.

CONTEXT: A standardised system to report outcomes and complications of urologic procedures has recently been proposed by an ad hoc European Association of Urology (EAU) Guidelines panel. To date, no studies have used these criteria to evaluate the quality of reports of outcomes and complications after partial nephrectomy (PN). OBJECTIVE: To address the quality of reporting of PN complications. DESIGN, SETTING, AND PARTICIPANTS: A systematic review of papers reporting outcomes of PN was conducted through the electronic search of databases, including Medline, PubMed, Embase, Scopus, and the Cochrane Database of Systematic Reviews. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Analysis was carried out on structured forms. The quality criteria that the EAU Working Group proposed for reporting complications were recorded for each paper, and adherence to the Martin criteria was assessed. RESULTS AND LIMITATIONS: Standardised criteria to report and grade complications were used in 71 out of 204 evaluable studies (34.8%). Only six studies (2.9%) fulfilled all criteria that the EAU Guidelines Office ad hoc panel proposed. The mean number did not change significantly by time or by surgical approach used. The most underreported criteria (in <50% of the studies) were who collected the data (18.6%), whether he or she were involved in the treatment (13.7%), duration of follow-up (47.1%), mortality data and causes of death (33.8%), definition of procedure-specific complications (39.2), separate reporting of intra- and postoperative complications (45.1%), complication severity or grade (32.4%), risk factors analysis (44.1%), readmission rates (12.7%), and percentage of patients lost to follow-up (6.9%). The mean number fulfilled was 6.5 ± 2.9 (mean plus or minus standard deviation) and did not change significantly by time or by surgical approach used. CONCLUSIONS: The only way to improve the quality of the surgical scientific literature and to allow sound comparisons among different approaches, especially with the lack of randomised trials, is the use of more rigorous methodology than the one recently proposed to report outcomes and complications. PATIENT SUMMARY: A rigorous methodology is mandatory when surgeons report about complications after surgery. Otherwise, the rate of adverse events is underestimated.

Laparoscopic pelvic lymph-node dissection in prostate cancer before external beam radiotherapy: Risk factors of nodal involvement and relapse following intended curative treatment.

OBJECTIVE: To report experience with laparoscopic pelvic lymph-node dissection (LPLND) in patients with prostate cancer before radiotherapy. Selection of risk factors for nodal involvement (N1) and recurrence following radiotherapy was made. MATERIAL AND METHODS: From November 1999 to June 2007, 177 patients with prostate cancer underwent LPLND at this department. The lymphadenectomy was limited to the obturator fossa bilaterally. Patients without nodal involvement were offered external beam radiotherapy with adjuvant hormone treatment. RESULTS: Complications occurred in 17 patients (9%). The majority of these were minor and were managed by conservative methods. Twenty-six patients (15%) were diagnosed with N1. High Gleason score and a high percentage of positive needle core biopsies were both risk factors of N1 as well as recurrent disease following radiotherapy (p<0.01 and 0.01, respectively). Clinically, T3 disease was associated with a risk of recurrence but not N1. High prostate-specific antigen (PSA) nadir was also a significant predictor of recurrence. Neither pretreatment PSA nor prostate volume was associated with N1 or recurrence. CONCLUSIONS: LPLND is a safe, well-established staging modality in clinically localized prostate cancer before radiotherapy. Risk factors upon diagnosis may be useful in the estimation of N1 and risk of recurrence.