640 research outputs found
Realistic Anatomical Prostate Models for Surgical Skills Workshops Using Ballistic Gelatin for Nerve-Sparing Radical Prostatectomy and Fruit for Simple Prostatectomy
PURPOSE: Understanding of prostate anatomy has evolved as techniques have been refined and improved for radical prostatectomy (RP), particularly regarding the importance of the neurovascular bundles for erectile function. The objectives of this study were to develop inexpensive and simple but anatomically accurate prostate models not involving human or animal elements to teach the terminology and practical aspects of nerve-sparing RP and simple prostatectomy (SP). MATERIALS AND METHODS: The RP model used a Foley catheter with ballistics gelatin in the balloon and mesh fabric (neurovascular bundles) and balloons (prostatic fascial layers) on either side for the practice of inter- and intrafascial techniques. The SP model required only a ripe clementine, for which the skin represented compressed normal prostate, the pulp represented benign tissue, and the pith mimicked fibrous adhesions. A modification with a balloon through the fruit center acted as a "urethra." RESULTS: Both models were easily created and successfully represented the principles of anatomical nerve-sparing RP and SP. Both models were tested in workshops by urologists and residents of differing levels with positive feedback. CONCLUSIONS: Low-fidelity models for prostate anatomy demonstration and surgical practice are feasible. They are inexpensive and simple to construct. Importantly, these models can be used for education on the practical aspects of nerve-sparing RP and SP. The models will require further validation as educational and competency tools, but as we move to an era in which human donors and animal experiments become less ethical and more difficult to complete, so too will low-fidelity models become more attractive
Promising role of preoperative neutrophil-to-lymphocyte ratio in patients treated with radical nephroureterectomy.
Several retrospective studies with small cohorts reported neutrophil-to-lymphocyte ratio (NLR) as a prognostic marker in upper tract urothelial carcinoma (UTUC) following radical nephroureterectomy (RNU). We aimed at validating the predictive and prognostic role of NLR in a large multi-institutional cohort.
Preoperative NLR was assessed in a multi-institutional cohort of 2477 patients with UTUC treated with RNU. Altered NLR was defined by a ratio >2.7. Logistic regression analyses were performed to assess the association between NLR and lymph node metastasis, muscle-invasive and non-organ-confined disease. The association of altered NLR with recurrence-free survival (RFS) and cancer-specific survival (CSS) was evaluated using Cox proportional hazards regression models.
Altered NLR was observed in 1428 (62.8 %) patients and associated with more advanced pathological tumor stage, lymph node metastasis, lymphovascular invasion, tumor necrosis and sessile tumor architecture. In a preoperative model that included age, gender, tumor location and architecture, NLR was an independent predictive factor for the presence of lymph node metastasis, muscle-invasive and non-organ-confined disease (p < 0.001). Within a median follow-up of 40 months (IQR 20-76 months), 548 (24.1 %) patients experienced disease recurrence and 453 patients (19.9 %) died from their cancer. Compared to patients with normal NLR, those with altered NLR had worse RFS (0.003) and CSS (p = 0.002). In multivariable analyses that adjusted for the effects of standard clinicopathologic features, altered NLR did not retain an independent value. In the subgroup of patients treated with lymphadenectomy in addition to RNU, NLR was independently associated with CSS (p = 0.03).
In UTUC, preoperative NLR is associated with adverse clinicopathologic features and independently predicts features of biologically and clinically aggressive UTUC such as lymph node metastasis, muscle-invasive or non-organ-confined status. NLR may help better risk stratify patients with regard to lymphadenectomy and conservative therapy
Concomitant CIS on TURBT does not impact oncological outcomes in patients treated with neoadjuvant or induction chemotherapy followed by radical cystectomy
© Springer-Verlag GmbH Germany, part of Springer Nature 2018Background: Cisplatin-based neoadjuvant chemotherapy (NAC) for muscle invasive bladder cancer improves all-cause and cancer specific survival. We aimed to evaluate whether the detection of carcinoma in situ (CIS) at the time of initial transurethral resection of bladder tumor (TURBT) has an oncological impact on the response to NAC prior to radical cystectomy. Patients and methods: Patients were identified retrospectively from 19 centers who received at least three cycles of NAC or induction chemotherapy for cT2-T4aN0-3M0 urothelial carcinoma of the bladder followed by radical cystectomy between 2000 and 2013. The primary and secondary outcomes were pathological response and overall survival, respectively. Multivariable analysis was performed to determine the independent predictive value of CIS on these outcomes. Results: Of 1213 patients included in the analysis, 21.8% had concomitant CIS. Baseline clinical and pathologic characteristics of the âCISâ versus âno-CISâ groups were similar. The pathological response did not differ between the two arms when response was defined as pT0N0 (17.9% with CIS vs 21.9% without CIS; p = 0.16) which may indicate that patients with CIS may be less sensitive to NAC or †pT1N0 (42.8% with CIS vs 37.8% without CIS; p = 0.15). On Cox regression model for overall survival for the cN0 cohort, the presence of CIS was not associated with survival (HR 0.86 (95% CI 0.63â1.18; p = 0.35). The presence of LVI (HR 1.41, 95% CI 1.01â1.96; p = 0.04), hydronephrosis (HR 1.63, 95% CI 1.23â2.16; p = 0.001) and use of chemotherapy other than ddMVAC (HR 0.57, 95% CI 0.34â0.94; p = 0.03) were associated with shorter overall survival. For the whole cohort, the presence of CIS was also not associated with survival (HR 1.05 (95% CI 0.82â1.35; p = 0.70). Conclusion: In this multicenter, real-world cohort, CIS status at TURBT did not affect pathologic response to neoadjuvant or induction chemotherapy. This study is limited by its retrospective nature as well as variability in chemotherapy regimens and surveillance regimens.Peer reviewedFinal Accepted Versio
Impact of renal function on eligibility for chemotherapy and survival in patients who have undergone radical nephroâureterectomy
Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/99046/1/bju11649.pd
RISK FACTORS FOR RESIDUAL DISEASE AT RE-TUR IN T1G3 BLADDER CANCER
INTRODUCTION AND OBJECTIVES: Goals of transurethral
resection of a bladder tumour (TUR) are to completely resect the lesions
and to make a correct diagnosis in order to adequately stage the patient.
It is well known that the presence of detrusor muscle in the
specimen is a prerequisite to minimize the risk of under staging.
Persistent disease after resection of bladder tumours is not uncommon
and is the reason why the European Guidelines recommended a reTUR
for all T1 tumours. It was recently published that when there is
muscle in the specimen, re-TUR does not influence progression or
cancer specific survival. We present here the patient and tumour factors
that may influence the presence of residual disease at re-TUR.
METHODS: In our retrospective cohort of 2451 primary T1G3
patients initially treated with BCG, pathology results for 934 patients
(38.1%) who underwent re-TUR are available. 75.4% had multifocal
tumours, 42.7% of tumours were more than 3 cm in diameter and 25.8%
had concomitant CIS. We analyse this subgroup of patients who underwent
re-TUR: there was no residual disease in 267 patients (28.6%)
and residual disease in 667 patients (71.4%): Ta in 378 (40.5%) and T1
in 289 (30.9%) patients. Age, gender, tumour status (primary/recurrent),
previous intravesical therapy, tumour size, tumour multi-focality, presence of concomitant CIS, and muscle in the specimen were analysed
in order to evaluate risk factors of residual disease at re-TUR,
both in univariate analyses and multivariate logistic regressions.
RESULTS: The following were not risk factors for residual disease:
age, gender, tumour status and previous intravesical chemotherapy.
The following were univariate risk factors for presence of
residual disease: no muscle in TUR, multiple tumours, tumours > 3 cm,
and presence of concomitant CISDue to the correlation between tumor
multi-focality and tumor size, the multivariate model retained either the
number of tumors or the tumor diameter (but not both), p < 0.001. The
presence of muscle in the specimen was no longer significant, p Œ 0.15,
while the presence of CIS only remained significant in the model with
tumor size, p < 0.001.
CONCLUSIONS: The most significant factors for a higher risk of
residual disease at re-TUR in T1G3 patients are multifocal tumours and
tumours more than 3 cm. Patients with concomitant CIS and those without
muscle in the specimen also have a higher risk of residual disease
Multicenter Validation of Histopathologic Tumor Regression Grade After Neoadjuvant Chemotherapy in Muscle-Invasive Bladder Carcinoma
Response classification after neoadjuvant chemotherapy in muscle-invasive bladder carcinoma is based on the TNM stage at radical cystectomy. We recently showed that histopathologic tumor regression grades (TRGs) add prognostic information to TNM. Our aim was to validate the prognostic significance of TRG in muscle-invasive bladder cancer in a multicenter setting. We enrolled 389 patients who underwent cisplatin-based chemotherapy before radical cystectomy in 8 centers between 2010 and 2016. Median follow-up was 2.2 years. TRG was determined in radical cystectomy specimens by local pathologists. Central pathology review was conducted in 20% of cases, which were randomly selected. The major response was defined as â€pT1N0. The remaining patients were grouped into partial responders (â„ypT2N0-3 and TRG 2) and nonresponders (â„ypT2N0-3 and TRG 3). TRG was successfully determined in all cases, and interobserver agreement in central pathology review was high (Îș=0.83). After combining TRG and TNM, 47%, 15%, and 38% of patients were major, partial, and nonresponders, respectively. Combination of TRG and TNM showed significant prognostic discrimination of overall survival (major responder: reference; partial responder: hazard ratio 3.5 [95% confidence interval: 1.8-6.8]; nonresponder: hazard ratio 6.1 [95% confidence interval: 3.6-10.3]). This discrimination was superior compared with TNM staging alone, supported by 2 goodness-of-fit criteria (P=0.041). TRG is a simple, reproducible histopathologic measurement of response to neoadjuvant chemotherapy in muscle-invasive bladder cancer. Integrating TRG with TNM staging resulted in significantly better prognostic stratification than TNM staging alone
Open Versus Robotic Cystectomy: A Propensity Score Matched Analysis Comparing Survival Outcomes
Background: To assess the differential effect of robotic assisted radical cystectomy (RARC) versus open radical cystectomy (ORC) on survival outcomes in matched analyses performed on a large multicentric cohort. Methods: The study included 9757 patients with urothelial bladder cancer (BCa) treated in a consecutive manner at each of 25 institutions. All patients underwent radical cystectomy with bilateral pelvic lymphadenectomy. To adjust for potential selection bias, propensity score matching 2:1 was performed with two ORC patients matched to one RARC patient. The propensity-matched cohort included 1374 patients. Multivariable competing risk analyses accounting for death of other causes, tested association of surgical technique with recurrence and cancer specific mortality (CSM), before and after propensity score matching. Results: Overall, 767 (7.8%) patients underwent RARC and 8990 (92.2%) ORC. The median follow-up before and after propensity matching was 81 and 102 months, respectively. In the overall population, the 3-year recurrence rates and CSM were 37% vs. 26% and 34% vs. 24% for ORC vs. RARC (all p values > 0.1), respectively. On multivariable Cox regression analyses, RARC and ORC had similar recurrence and CSM rates before and after matching (all p values > 0.1). Conclusions: Patients treated with RARC and ORC have similar survival outcomes. This data is helpful in consulting patients until long term survival outcomes of level one evidence is available
Enseignement et perception de lâurologie Ă la fin du deuxiĂšme cycle des Ă©tudes mĂ©dicales : Ă©tat des lieux
Objectifs
DĂ©terminer la perception de lâurologie par les Ă©tudiants en fin de deuxiĂšme cycle des Ă©tudes mĂ©dicales (DCEM) et connaĂźtre leurs supports dâenseignement.
Matériel et méthodes
Un auto-questionnaire a été diffusé par internet à 1600 étudiants de 16 facultés au cours de leur dernier semestre de DCEM.
RĂ©sultats
Au total, 590 rĂ©ponses ont Ă©tĂ© reçues (36,8 %). Dans notre population, 70,2 % des Ă©tudiants Ă©taient des femmes. Parmi eux, 24,1 % avaient fait un stage en urologie. Lâurologie Ă©tait considĂ©rĂ©e comme une discipline mĂ©dicale, chirurgicale et mĂ©dicochirurgicale, respectivement par 3,7 %, 37,8 % et 58 % dâentre eux. Lâurologie Ă©tait considĂ©rĂ©e comme une discipline trĂšs importante, importante, peu importante et pas importante par 5,1 %, 54,4 %, 37,5 % et 2,4 % dâentre eux. Les supports dâenseignement les plus utilisĂ©s pour prĂ©parer lâexamen national classant (ENC) Ă©taient les polycopiĂ©s dâinternat (45,3 %), les confĂ©rences dâinternat (43,7 %), le polycopiĂ© national du collĂšge dâUrologie (38,6 %) et les cours dispensĂ©s Ă la facultĂ© (32 %). Les items dâurologie les mieux assimilĂ©s Ă©taient les pathologies lithiasiques (86,3 %), les troubles urinaires du bas appareil (76,3 %) et les cancers urologiques (56,7 %). Ă lâinverse, seulement 34,7 % et 28 % considĂ©raient leurs connaissances suffisantes sur la dysfonction Ă©rectile et la transplantation rĂ©nale. Enfin, 7,5 % exprimaient le souhait de devenir urologue. La rĂ©alisation dâun stage en urologie Ă©tait associĂ©e au sentiment dâavoir acquis les connaissances pour dĂ©buter lâinternat (p < 0,001) et au souhait dâĂȘtre urologue (p < 0,001).
Conclusion
Contre toute attente, lâurologie Ă©tait considĂ©rĂ©e comme une discipline mĂ©dicochirurgicale importante par la moitiĂ© des Ă©tudiants en fin de DCEM malgrĂ© le faible nombre dâitems dĂ©diĂ©s Ă lâurologie dans le programme de lâENC. Un tiers dâentre eux utilisaient le polycopiĂ© national du collĂšge dâUrologie pour prĂ©parer lâENC et un quart avait rĂ©alisĂ© un stage en urologie
Evaluation of gas chromatography mass spectrometry and pattern recognition for the identification of bladder cancer from urine headspace
Previous studies have indicated that volatile organic compounds specific to bladder cancer may exist in urine headspace, raising the possibility that they may be of diagnostic value for this particular cancer. To further examine this hypothesis, urine samples were collected from patients diagnosed with either bladder cancer or a non-cancerous urological disease/infection, and from healthy volunteers, from which the volatile metabolomes were analysed using gas chromatography mass spectrometry. The acquired data were subjected to a specifically designed pattern recognition algorithm, involving cross-model validation. The best diagnostic performance, achieved with independent test data provided by healthy volunteers and bladder cancer patients, was 89% overall accuracy (90% sensitivity and 88% specificity). Permutation tests showed that these were statistically significant, providing further evidence of the potential for volatile biomarkers to form the basis of a non-invasive diagnostic technique
Diagnostic Ureteroscopy for Upper Tract Urothelial Carcinoma is Independently Associated with Intravesical Recurrence after Radical Nephroureterectomy
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