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Este mes en... Canadian Urological Association Journal

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Este mes en... Canadian Urological Association Journal:


  • Raising the bar for bladder cancer care
  • Go West: CUA annual meeting provides enriching education in a majestic setting
  • Vers l’Ouest pour le prochain congrès annuel de l’AUC : Poursuivre sa formation dans un décor majestueux
  • The many hats of a community urologist
  • Health advocacy in a competency-based curriculum: The emerging role of global surgery
  • First Canadian experience with robotic single-incision pyeloplasty: Comparison with multi-incision technique

    Introduction: We compared the outcomes of single-incision, robotassisted laparoscopic pyeloplasty vs. multiple-incision pyeloplasty using the da Vinci robotic system.

    Methods: We reviewed all consecutive robotic pyeloplasties by a single surgeon from January 2011 to August 2015. A total of 30 procedures were performed (16 single:14 multi-port). Two different single-port devices were compared: the GelPort (Applied Medical, Rancho Santa Margarita, CA) and the Intuitive single-site access port (Intuitive Surgical, Sunnyvale, CA).

    Results: Patient demographics were similar between the two groups. Mean operating time was similar among the single and multi-port groups (225.2 min vs. 198.9 minutes [p=0.33]). There was no significant difference in length of hospital stay in either group (86.2 hr vs. 93.2 hr [p=0.76]). There was no difference in success rates or postoperative complications among groups.

    Conclusions: Single-port robotic pyeloplasty is non-inferior to multiple-incision robotic surgery in terms of operative times, hospitalization time, success rates, and complications. Verifying these results with larger cohorts is required prior to the wide adoption of this technique. Ongoing objective measurements of cosmesis and patient satisfaction are being evaluated.

     

  • Enumerating pelvic recurrence following radical cystectomy for bladder cancer: A Canadian multi-institutional study

    Introduction: We aimed to enumerate the rate of pelvic recurrence following radical cystectomy at university-affiliated hospitals in Canada.

    Methods: Canadian, university-affiliated hospitals were invited to participate. They were asked to identify the first 10 consecutive patients undergoing radical cystectomy starting January 1, 2005, who had urothelial carcinoma stages pT3/T4 N0-2 M0. The first 10 consecutive cases starting January 1, 2005 who met these criteria were the patients submitted by that institution with information regarding tumour stage, age, number of nodes removed, and last known clinical status in regard to recurrence and patterns of failure.

    Results: Of the 111 patients, 80% had pT3 and 20% pT4 disease, with 62% being node-negative, 14% pN1, and 27% pN2; 57% had 10 or more nodes removed. Cumulative incidence of pelvic relapse was 40% among the entire group

    Conclusions: This review demonstrates a high rate of pelvic tumour recurrence following radical cystectomy for pT3/T4 urothelial cancer.

  • Gravity-assisted drainage imaging in the assessment of pediatric hydronephrosis

    Introduction: As early detection of hydronephrosis increases, we require better methods of distinguishing between pediatric patients who require pyeloplasty vs. those with transient obstruction. Gravity-assisted drainage (GAD) as part of a standardized diuretic renography protocol has been suggested as a simple and safe method to differentiate patients.

    Methods: Renal scans of 89 subjects with 121 hydronephrotic renal units between January 2004 and March 2007 were identified and analyzed.

    Results: Of all renal units, 65% showed obstruction. GAD maneuver resulted in significant residual tracer drainage in eight renal units, moderate drainage in 12 renal units, and some improvement in 40 units after the GAD maneuver. Of the eight renal units with significant residual tracer drainage, only two proceeded to pyeloplasty. After pyeloplasty, nine children had improved time to half maximum (T1/2 Max) and 13 were unchanged.

    Conclusions: Our study was limited due to its retrospective design and descriptive analyses, but includes a sufficient number of subjects to conclude that GAD as part of a diuretic renography protocol is an effective and simple technique that can help prevent unnecessary surgical procedures in pediatric patients.

  • Efficacy, quality of life, and safety of cabazitaxel in Canadian metastatic castration-resistant prostate cancer patients treated or not with prior abiraterone

    Introduction: In the TROPIC study, cabazitaxel improved overall survival in abiraterone-naïve metastatic castration-resistant prostate cancer (mCRPC) patients post-docetaxel. To evaluate cabazitaxel in routine clinical practice, an international, single-arm trial was conducted. Efficacy, safety, and quality of life (QoL) data were collected from Canadian patients enrolled. Overall survival and progression-free survival were not collected as part of this study. Importantly, prior abiraterone use was obtained and its impact on clinical parameters was examined.

    Methods: Sixty-one patients from nine Canadian centres were enrolled, with prior abiraterone use known for 60 patients. Prostatespecific antigen (PSA) response rate, safety, and impact on QoL life were analyzed as a function of prior abiraterone use.

    Results: Overall, 92% of patients were ECOG 0/1, 88% had bone metastases, and 25% visceral metastases. Patients treated without prior abiraterone (NoPriorAbi) (n=35, 58%) and with prior abiraterone (PriorAbi) (n=25, 42%) had similar baseline characteristics, except for age and prior cumulative docetaxel dose. Median number of cabazitaxel cycles received was similar between groups (NoPriorAbi=6, PriorAbi=7), as was PSA response rate (NoPriorAbi=36.4%, PriorAbi=45.0%, p=0.54). Almost one-third (31%) of patients received prophylactic granulocyte colony-stimulating factors. Most frequent Grade 3/4 toxicities were neutropenia (14.8%); anemia, febrile neutropenia, fatigue (each at 9.8%); and diarrhea (8.2%). No treatment-related adverse event leading to death was observed. QoL and pain were improved with no difference seen between groups. Treatment discontinuation was mainly due to disease progression (45.9%) and adverse events (32.8%).

    Conclusions: In routine clinical practice, cabazitaxel’s risk-benefit ratio in mCRPC patients previously treated with docetaxel seems to be maintained independent of prior abiraterone use.

  • A simple prognostic model for overall survival in metastatic renal cell carcinoma

    Introduction: The primary purpose of this study was to develop a simpler prognostic model to predict overall survival for patients treated for metastatic renal cell carcinoma (mRCC) by examining variables shown in the literature to be associated with survival.

    Methods: We conducted a retrospective analysis of patients treated for mRCC at two Canadian centres. All patients who started first-line treatment were included in the analysis. A multivariate Cox proportional hazards regression model was constructed using a stepwise procedure. Patients were assigned to risk groups depending on how many of the three risk factors from the final multivariate model they had.

    Results: There were three risk factors in the final multivariate model: hemoglobin, prior nephrectomy, and time from diagnosis to treatment. Patients in the high-risk group (two or three risk factors) had a median survival of 5.9 months, while those in the intermediate-risk group (one risk factor) had a median survival of 16.2 months, and those in the low-risk group (no risk factors) had a median survival of 50.6 months.

    Conclusions: In multivariate analysis, shorter survival times were associated with hemoglobin below the lower limit of normal, absence of prior nephrectomy, and initiation of treatment within one year of diagnosis.

  • Diagnosis, referral, and primary treatment decisions in newly diagnosed prostate cancer patients in a multidisciplinary diagnostic assessment program

    Introduction: We aimed to report on data from the multidisciplinary diagnostic assessment program (DAP) at the Gale and Graham Wright Prostate Centre (GGWPC) at North York General Hospital (NYGH). We assessed referral, diagnosis, and treatment decisions for newly diagnosed prostate cancer (PCa) patients as seen over time, risk stratification, and clinic type to establish a deeper understanding of current decision-making trends.

    Methods: From June 2007 to April 2012, 1277 patients who were diagnosed with PCa at the GGWPC were included in this study. Data was collected and reviewed retrospectively using electronic patient records.

    Results: 1031 of 1260 patients (81.8%) were seen in a multidisciplinary clinic (MDC). Over time, a decrease in low-risk (LR) diagnoses and an increase intermediate-risk (IR) diagnoses was observed
    (p<0.0001). With respect to overall treatment decisions 474 (37.1%) of patients received primary radiotherapy, 340 (26.6%) received surgical therapy, and 426 (33.4%) had conservative management;
    57% of patients who were candidates for active surveillance were managed this way. No significant treatment trends were observed over time (p=0.8440). Significantly, different management decisions
    were made in those who attended the MDC compared to those who only saw a urologist (p<0.0001).

    Conclusions: In our DAP, the vast majority of patients presented with screen-detected disease, but there was a gradual shift from low- to intermediate-risk disease over time. Timely multidisciplinary
    consultation was achievable in over 80% of patients and was associated with different management decisions. We recommend that all patients at risk for prostate cancer be worked up in a multidisciplinary DAP.

  • Laparoscopic nephroureterectomy is associated with higher risk of adverse events compared to laparoscopic radical nephrectomy

    Background: Laparoscopic radical nephrectomy (LRN) and laparoscopic nephroureterectomy (LNU) are similar procedures and some surgeons may counsel both patients groups the same regarding peri-operative risks. The objective of this study is to compare complications following LRN and LNU.

    Patients and methods: A historical cohort of patients who received LRN or LNU between 2006 and 2012 was reviewed from the National Surgical Quality Improvement Program (NSQIP) database. Patient and surgical characteristics, and outcomes up to 30-days post-operative were abstracted. Univariable and multivariable associations between procedure (LRN or LNU) and any adverse event were determined.

    Results: During the study period, 4904 patients met inclusion criteria. Of these, 4159 (85%) received a LRN while 745 (15%) received a LNU. LNU was associated with more complications than LRN (21% vs. 12%, respectively, p-value <0.01). The most common complications for LNU vs. LRN, respectively, were: bleeding requiring blood transfusion (9.0% vs. 6.0%), urinary tract infection (4.6% vs. 1.5%), wound infection (1.3% vs. 1.8%), and unplanned intubation (2.3% vs. 0.9%). On multivariable analysis, LNU was associated with higher risk of any complication compared to LRN (RR 1.41, 95% CI 1.16-1.72).  

    Conclusions: Post-operative complications within 30 days of surgery are common after LNU and LRN. Despite having technical similarities, LNU carries a significantly higher risk of short-term complications compared to LRN. This information should be considered when counseling patients prior to surgery.

  • CAPRA-S predicts outcome for adjuvant and salvage external beam radiotherapy after radical prostatectomy

    Introduction: We aimed to evaluate the predictive value of the Cancer of the Prostate Risk Assessment Postsurgical Score (CAPRA-S) for patients treated with radical prostatectomy followed by subsequent external beam radiotherapy (EBRT).

    Methods: A total of 373 patients treated with EBRT between January 2000 and June 2015 were identified in the institutional database. Followup and complete CAPRA-S score were available for 334 (89.5%) patients. CAPRA-S scores were sorted into previously defined categories of low- (score 0‒2), intermediate- (3‒5), and high-risk (6‒12). Time to biochemical recurrence (BCR) was defined as prostate-specific antigen (PSA) >0.20 ng/mL after EBRT. Survival analyses were performed using the Kaplan-Meier method and comparisons were made using the log-rank test.

    Results: Overall median time from surgery to EBRT was 18 months (interquartile range [IQR] 8‒36) and median followup since EBRT was 48 months (IQR 28‒78). CAPRA-S predicted time to BCR (<0.001), time to palliative androgen-deprivation therapy (ADT) (p=0.017), and a trend for significantly predicting overall survival (OS, p=0.058). On multivariate analysis, the CAPRA-S was predictive of time to BCR only (low-risk vs. intermediate-risk; hazard ratio [HR] 0.14, 95% confidence interval [CI] 0.043‒0.48, p=0.001). The last PSA measurement before EBRT as a continuous and grouped variable proved highly significant in predicting all outcomes tested, including OS (p≤0.002).

    Conclusions: CAPRA-S predicts time to BCR and freedom from palliative ADT, and is borderline significant for OS. Together with the PSA before EBRT, CAPRA-S is a useful, predictive tool. The main limitation of this study is its retrospective design.

  • Anticholinergic use in children: Persistence and patterns of therapy

    Introduction: Overactive bladder (OAB) symptoms are complex and generally require long-term therapy. Nevertheless, it has been demonstrated that persistence rates of antimuscarinic drug use are low in adults. Better understanding of the treatment patterns of children treated with antimuscarinics could help to improve drug management. Our objective was to evaluate persistence rates of patients under 20 years of age on antimuscarinic therapy over a four-year period.

    Methods: Patients having received a first-ever antimuscarinic drug prescription between April 2007 and March 2008 were identified using IMS Brogan’s Public and Private Drug Plans database. Canadian drug claims data from Private Drug Plans, Régie de l’Assurance Maladie du Québec, and Ontario Public Drug Plans were analyzed retrospectively. Patients were followed for four years to assess the prescribed drugs, the lines of treatment, and the duration of each treatment.

    Results: Data were available for 374 patients. The most prescribed drug as a first-line therapy was oxybutynin (87.2%), followed by tolterodine LA (5.9%). Patients refilled their index prescriptions for an average of 429 days. Solifenacin had the highest mean duration of index therapy (765 days). The median number of antimuscarinics prescribed was one. At the end of the followup, 44 patients were still on therapy. Reasons for discontinuation of treatment were not available.

    Conclusions: Overall discontinuation rate of antimuscarinic therapy in children is comparable to what has been reported in adult patients with OAB. However, children seem to persist on the medication for a longer duration before adherence rates start declining. The low rate of persistence highlights the need to identify the reasons for discontinuation of therapy in children in order to obtain better persistence rates.

  • Percutaneous nephrolithotomy with one-shot dilation method: Is it safe in patients who had open surgery before?

    Introduction: This study aimed to evaluate whether one-shot dilatation technique is as safe in patients with a history of open-stone surgery as it is in patients without previous open-stone surgery.

    Methods: Between January 2007 and February 2015, 82 patients who underwent percutaneous nephrolithotomy (PNL) surgery with one-shot dilation technique who previously had open-stone surgery were retrospectively reviewed and evaluated (Group 1). Another 82 patients were selected randomly among patients who had PNL with one-shot dilation technique, but with no history of open renal surgery (Group 2). Age, gender, type of kidney stone , duration of surgery, radiation exposure time, and whether or not there was any bleeding requiring perioperative and postoperative transfusion were noted for each patient.

    Results: The stone-free rates, operation and fluoroscopy time, and peroperative and postoperative complication rates were similar in both groups (p>0.05).

    Conclusions: Our experience indicated that PNL with one-shot dilation technique is a reliable method in patients with a history of open-stone surgery.

  • Robotic-assisted, single-site surgery: Having your surgical cake and eating it too!
  • Mitigating pelvic recurrence and improving overall survival
  • The challenges of diagnosing obstructive hydronephrosis in children
  • Assessing the utility of cabazitaxel in mCRPC
  • The neutrophil-to-lymphocyte ratio in clinical practice
  • Author reply: The neutrophil-to-lymphocyte ratio in clinical practice
  • Dr. Donald A. Grace
  • Dr. Lawrence W. Mix
  • Université Laval
 

 

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