The natural history of low-risk non-muscle-invasive bladder cancer: a collaborative multi-centre study.

BACKGROUND: International guidelines vary in terms of their definition and recommendation for management of low-risk non-muscle-invasive bladder cancer (LRNMIBC). The ideal management for this large subset of bladder cancer patient remains unclear. OBJECTIVE: To evaluate long-term outcomes of patients with LRNMIBC. As a secondary objective, to assess for intergroup heterogeneity in disease-specific outcomes between G1 and G2LG diseases. METHODS: A multi-centre, retrospective study of patients who met the 2015 NICE definition of LRNMIBC. Timeline of diagnosis ranged from 01/01/2012 to 30/06/2016. RESULTS: A total 390 patients had available follow-up data (G1: 142, G2LG: 249). Over a median follow-up time of 36 months (IQR 25-50), 29.2% of the patients developed a recurrence. G2LG patients were statistically more likely to develop a recurrence (G1: 26.8%, G2LG: 33.7%, p < 0.05). 51.8% of recurrences occurred after 1 year of surveillance. Progression to high-grade disease occurred in 1.8% (n = 7, G1: 3, G2LG: 4) and a further 1.0% (n = 4, G1:3, G2LG: 1) of patients developed muscle-invasive bladder cancer (MIBC). CONCLUSION: The majority of recurrences occurred after 1 year of surveillance. The risk of disease progression was low; however, this was observed in a cohort of patients with regular cystoscopic follow-up. The risk may be higher if patients were pre-maturely discharged. If a 5-year surveillance programme were to be followed, 96.5% of recurrences would be captured. Lastly, there appears to be intergroup heterogeneity within LRNMIBC with G2LG patients having a statistically higher risk of recurrence compared to G1.

¿Puede la cirugía mínimamente invasiva resultar en sitios inusuales de metástasis? / Does minimally invasive surgery for bladder cancer result in unusual sites of metastasis?

Objetivo: Comparar los sitios de metástasis desarrolladas tras procedimientos de abordaje laparoscópico (CRL) y abierto (CRA) en una cohorte de pacientes en un hospital distrital. La morbilidad y la mortalidad de los dos abordajes se evalúan utilizando las variables secundarias de tiempo de estancia hospitalaria y la tasa de complicaciones. Se comparan la tasa y el sitio de metástasis.MétodosSe llevó a cabo una revisión retrospectiva de las anotaciones clínicas de todos los pacientes sometidos a cistectomía por cáncer de vejiga en el Pinderfields General Hospital de Wakefield entre 2010 y 2016 (n=219). Fueron 150 hombres y 69 mujeres, y 107 casos tratados con abordaje mínimamente invasivo y 87 con abordaje abierto (faltan datos sobre 25 casos). Los datos fueron analizados usando Microsoft Excel XLSTAT.ResultadosLa tasa de recurrencia fue del 25,1% y no difirió significativamente respecto al abordaje (p=0,89). Los sitios de recurrencia tampoco difirieron respecto al abordaje quirúrgico, siendo los más frecuentes la pelvis, los pulmones y los huesos. Los sitios inusuales de recurrencia fueron la pared abdominal y el colon sigmoide, en ambos casos, desarrolladas tras procedimientos de CRL. El tiempo de estancia hospitalaria fue mayor para el abordaje abierto (mediana CRL=10, CRA=13, p<0,01). La supervivencia a 5 años fue del 74,9%. La distribución de la supervivencia no difirió significativamente entre los dos abordajes quirúrgicos (p=0,43), y no hubo una asociación significativa entre el abordaje quirúrgico y la muerte del paciente durante el período de seguimiento (p=0,09). La tasa de estenosis fue del 4,1%, sin presentar diferencias significativas entre los dos grupos (p=0,29). El tiempo hasta el desarrollo de la estenosis fue de 130 días. Las puntuaciones de Clavien-Dindo para las complicaciones no difirieron entre abordajes (p=0,93), y tampoco hubo una asociación significativa entre el abordaje quirúrgico y el desarrollo de complicaciones (p=0,19). (AU)

Objective: To compare sites of metastasis for the laparoscopic (LRC) and open (ORC) approaches in a cohort of patients at a district general hospital. Morbidity and mortality for the two approaches are assessed using secondary outcomes of length of stay and complication rate. Metastasis rate and site are compared.MethodsA retrospective case note review was carried out for all patients who underwent cystectomy for bladder malignancy at Pinderfields General Hospital, Wakefield between 2010 and 2016 (n=219). There were 150 males and 69 females in 107 minimally invasive cases and 87 open (missing data on 25 cases). Data were analysed using Microsoft Excel XLSTAT.ResultsRecurrence rate was 25.1% and did not differ significantly with approach (p=0.89). Sites of recurrence did not differ with operative approach, the most frequent being pelvis, chest and bone. Unusual sites of recurrence included abdominal wall and sigmoid colon which both occurred in LRC. Length of stay was greater for the open approach (median LRC=10, ORC=13, p<0.01). Five-year survival was 74.9%. Survival distribution did not significantly differ with operative approach (p=0.43), and there was no significant association between operative approach and patient death within the follow-up period (p=0.09). Stricture rate was 4.1% and was not significantly different between the two groups (p=0.29). Median time to stricture was 130 days. Clavien-Dindo scores for complications did not differ with approach (p=0.93), and there was no significant association between operative approach and whether complications developed (p=0.19). (AU)

Does minimally invasive surgery for bladder cancer result in unusual sites of metastasis?

BACKGROUND: To compare sites of metastasis for the laparoscopic (LRC) and open (ORC) approaches in a cohort of patients at a district general hospital. Morbidity and mortality for the two approaches are assessed using secondary outcomes of length of stay and complication rate. Metastasis rate and site are compared. METHODS: A retrospective case note review was carried out for all patients who underwent cystectomy for bladder malignancy at Pinderfields General Hospital, Wakefield between 2010 and 2016 (n = 219). There were 150 males and 69 females in 107 minimally invasive cases and 87 open (missing data on 25 cases). Data were analysed using Microsoft Excel XLSTAT. RESULTS: Recurrence rate was 25.1% and did not differ significantly with approach (p = 0.89). Sites of recurrence did not differ with operative approach, the most frequent being pelvis, chest and bone. Unusual sites of recurrence included abdominal wall and sigmoid colon which both occurred in LRC. Length of stay was greater for the open approach (median LRC = 10, ORC = 13, p < 0.01). Five-year survival was 74.9%. Survival distribution did not significantly differ with operative approach (p = 0.43), and there was no significant association between operative approach and patient death within the follow-up period (p = 0.09). Stricture rate was 4.1% and was not significantly different between the 2 groups (p = 0.29). Median time to stricture was 130 days. Clavien-Dindo scores for complications did not differ with approach (p = 0.93), and there was no significant association between operative approach and whether complications developed (p = 0.19). CONCLUSIONS: The adverse oncological outcomes in minimally invasive approaches suggested by some studies are not confirmed here. Those in the LRC group were discharged sooner, though this did not translate into differences in morbidity or survival. Analysis of the association between individual complications and length of stay may clarify this further. Shorter hospital stay is also likely to have significant financial implications. Despite no significant difference in outcomes, the findings demonstrate potential benefits of LRC. Extensions of this study could include: cost-benefit analysis, examination of individual complications' effect on length of stay; and analysis of approach-specific factors contributing to perioperative deaths.

Renal transplantation in Indo-Asian patients in the UK.

Membership of some ethnic groups has an effect on renal transplant outcome but little is known about the impact of Indo-Asian ethnicity, despite this group's high incidence of renal disease. We compared outcomes in Indo-Asians and Caucasians at the Hammersmith Hospital (Indo-Asians, N = 46; Caucasians, N = 90), in the Long-Term Efficacy and Safety Surveillance (LOTESS) database of cyclosporin-treated renal transplant recipients (Indo-Asians, N = 254; Caucasians, N = 4262) and the National Transplant Database held by UK Transplant (Indo-Asians, N = 459; Caucasians, N = 4831). The baseline demographic and co-morbid characteristics of the two ethnic groups were comparable, save for more diabetes in the Indo-Asian community. Following transplantation, the incidence of delayed graft function and steroid-resistant acute rejection were also comparable, as were graft and patient survival (out to 5 years) and graft function. In addition, post-transplant blood pressure, levels of cholesterol and triglycerides and exposure to corticosteroids and cyclosporin were comparable. However, when patients who were not diabetic before transplantation were studied separately, there was an increased incidence of diabetes in the Indo-Asian community (Hammersmith data: Indo-Asians 10.9% vs. Caucasians 3.3%, p = 0.02; LOTESS data Indo-Asians 5.5% vs. Caucasians 1.6%, p < 0.0001). Subsequent management of this group should pursue immunosuppressive regimens less likely to impair post-transplant glucose tolerance.

Unusual perianal tumours masquerading as abscesses.

Tumours of the perianal region and anal canal are uncommon and can present in a variety of ways. Acute anorectal sepsis is a common condition that usually presents as a painful lump close to the anal margin. Tumours in the perianal region may mimic the symptoms and signs of anorectal sepsis, thereby leading to a delay in diagnosis and management. We report three patients who presented to our department with symptoms and signs suggestive of perianal abscess but which on further investigation were discovered to be due to unusual perianal tumours. Only one of the tumours was found to be malignant--a primary perianal mucinous adenocarcinoma; the other two were benign, a leiomyoma and an aggressive angiomyxoma. A high index of clinical suspicion is required to the diagnosis of perianal tumours when assessing patients with painful perianal lumps, particularly those with a long history and those of ethnic origin. Every effort should be made to establish a preoperative diagnosis so that correct treatment can be delivered.

Effects of alpha-cyano-4-hydroxycinnamic acid on fatigue and recovery of isolated mouse muscle.

Fatigue and recovery of mouse soleus and extensor digitorum longus muscles were investigated in standard saline and in saline containing the lactate + hydrogen ion transport blocker, alpha-cyano-4-hydroxycinnamic acid (cinnamate). The fatigue protocol was a series of brief isometric tetani which reduced isometric force by about 25%. Recovery was monitored by test tetani during recovery. Both muscles recovered completely in standard saline. Soleus muscle also recovered completely in the presence of cinnamate, whereas extensor digitorum longus hardly recovered at all. Force during fatigue and recovery can be described in a mathematical simulation in which force depends on intracellular inorganic phosphate and pH, and the only effect of cinnamate is to block lactate + hydrogen ion transport. The results of the simulation suggest that during the fatiguing series of tetani pH changes are small and have a negligible effect on force, but pH is a major determinant of the timecourse of recovery in extensor digitorum longus.