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Video: Trends in renal function after RN

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Trends in renal function after radical nephrectomy: a multicentre analysis

Jae S. Chung1, Nak H. Son2, Seok-Soo Byun6, Sang E. Lee6, Sung K. Hong6, Chang W. Jeong6, Sang C. Lee6, Dong-Wan Chae7, Won S. Choi8, Yong H. Park3, Sung H. Hong4, Yong J. Kim9 and Seok H. Kang5

1Department of Urology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, 2Department of Biostatistics, Yonsei University College of Medicine, 3Department of Urology, Seoul National University Hospital, 4Department of Urology, Seoul St. Mary’s Hospital, 5Department of Urology, Korea University Anam Hospital, Seoul, 6Departments of Urology and 7Internal Medicine, Seoul National University Bundang Hospital, Seongnam, 8Choi Won Suk Urology Clinic, Yongin, and 9Department of Urology, Chungbuk National University Hospital, Cheongju, Korea

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OBJECTIVE

• To evaluate serial changes in renal function by investigating various clinical factors after radical nephrectomy (RN).

PATIENTS AND METHODS

• The study population consisted of 2068 consecutive patients who were treated at multiple institutions by RN for renal cortical tumour without metastasis between 1999 and 2011.

• We measured the serial change in estimated glomerular filtration rate (eGFR) and clinical factors during a 60-month follow-up period.

• The changes in eGFR over time were analysed according to baseline eGFR (eGFR ≥60 and 15–59 mL/min/1.73m2) using a linear mixed model.

• The independent prognostic value of various clinical factors on the increase in eGFR was ascertained by multivariate mixed regression model.

RESULTS

• Overall, there was a subsequent restoration of renal function over the 60 months.

• The slope for the relationship between the eGFR and the time since RN was 0.082 (95% confidence interval [CI] 0.039–0.104; P < 0.001) and 0.053 (95% CI 0.006–0.100; P = 0.038) in each baseline group, indicating that each month after RN was associated with an increase in eGFR of 0.082 and 0.053 mL/min/1.73m2, respectively.

• When we analysed renal function based on various factors, postoperative eGFR of patients with diabetes mellitus, old age (≥70 years) or a preoperative eGFR of <30 mL/min/1.73 m2, was decreased or maintained at a certain level without any improvement in renal function.

• Preoperative predictors of an increase in eGFR after RN were young age, no DM, no hypertension, a preoperative eGFR of ≥30 mL/min/1.73m2 and time after surgery (≥36 months).

CONCLUSIONS

• Renal function recovered continuously during the 60-month follow-up period after RN.

• However, the trends in functional recovery change were different according to various clinical factors and such information should be discussed with patients when being counselled about their treatment for renal cell carcinoma (RCC).

 

Video: Why the Melbourne Statement?

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The Melbourne Consensus Statement on the early detection of prostate cancer

Declan G. Murphy1,2,3, Thomas Ahlering4, William J. Catalona5, Helen Crowe2,3, Jane Crowe3, Noel Clarke10, Matthew Cooperberg6, David Gillatt11, Martin Gleave12, Stacy Loeb7, Monique Roobol14, Oliver Sartor8, Tom Pickles13, Addie Wootten3, Patrick C. Walsh9 and Anthony J. Costello2,3

1Peter MacCallum Cancer Centre, 2Royal Melbourne Hospital, University of Melbourne, 3Epworth Prostate Centre, Australian Prostate Cancer Research Centre, Epworth Healthcare Richmond, Melbourne, Vic., Australia, 4School of Medicine, University of California, Irvine, 5Northwestern University Feinberg School of Medicine, Chicago, IL, 6Helen Diller Family Comprehensive Cancer Centre, University of California, San Francisco, 7New York University, 8Tulane University School of Medicine, Tulane, 9The James Buchanan Brady Urological Institute, Johns Hopkins University, USA, 10The Christie Hospital, Manchester University, Manchester, 11Bristol Urological Institute, University of Bristol, Bristol, UK, 12The Vancouver Prostate Centre, 13BC Cancer Agency, University of British Columbia, Vancouver, Canada, and 14Erasmus University Medical Centre, Rotterdam, The Netherlands

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• Various conflicting guidelines and recommendations about prostate cancer screening and early detection have left both clinicians and their patients quite confused. At the Prostate Cancer World Congress held in Melbourne in August 2013, a multidisciplinary group of the world’s leading experts in this area gathered together and generated this set of consensus statements to bring some clarity to this confusion.

• The five consensus statements provide clear guidance for clinicians counselling their patients about the early detection of prostate cancer.

 

Video: PCa in older men, is it really low-grade disease?

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Initial management of prostate-specific antigen-detected, low-risk prostate cancer and the risk of death from prostate cancer

Ayal A. Aizer*, Ming-Hui Chen‡, Jona Hattangadi* and Anthony V. D’Amico†

*Harvard Radiation Oncology Program, Boston, MA, †Department of Radiation Oncology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA, and, ‡Department of Statistics, University of Connecticut, Storrs, CT, USA

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OBJECTIVE

• To evaluate whether older age in men with low-risk prostate cancer increases the risk of prostate cancer-specific mortality (PCSM) when non-curative approaches are selected as initial management.

PATIENTS AND METHODS

• The study cohort consisted of 27 969 men, with a median age of 67 years, with prostate-specific antigen (PSA)-detected, low-risk prostate cancer (clinical category T1c, Gleason score ≤6, and PSA ≤10) identified by the Surveillance, Epidemiology and End Results programme between 2004 and 2007.

• Fine and Gray’s competing risk regression analysis was used to evaluate whether management with non-curative vs curative therapy was associated with an increased risk of PCSM after adjusting for PSA level, age at diagnosis and year of diagnosis.

RESULTS

• After a median follow-up of 2.75 years, 1121 men died, 60 (5.4%) from prostate cancer.

• Both older age (adjusted hazard ratio [AHR] 1.05; 95% confidence interval (CI) 1.02–1.08; P < 0.001) and non-curative treatment (AHR 3.34; 95% CI 1.97–5.67; P < 0.001) were significantly associated with an increased risk of PCSM.

• Men > the median age experienced increased estimates of PCSM when treated with non-curative as opposed to curative intent (P< 0.001); this finding was not seen in men ≤ the median age (P = 0.17).

CONCLUSION

• Pending prospective validation, our study suggests that non-curative approaches for older men with ‘low-risk’ prostate cancer result in an increased risk of PCSM, suggesting the need for alternative approaches to exclude occult, high grade prostate cancer in these men.

 

Video: Survival for RCC and nodal metastases

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Extent of lymphadenectomy does not improve the survival of patients with renal cell carcinoma and nodal metastases: biases associated with the handling of missing data

Maxine Sun*, Quoc-Dien Trinh*‡, Marco Bianchi*, Jens Hansen*††, Firas Abdollah, Zhe Tian*, Shahrokh F. Shariat§, Francesco Montorsi, Paul Perrotte† and Pierre I. Karakiewicz*†

*Cancer Prognostics and Health Outcomes Unit, †Department of Urology, University of Montreal Health Center, Montreal, Canada, ‡Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, §Department of Urology,Weill Medical College of Cornell University, New York, NY, USA, Department of Urology, Vita-Salute San Raffaele University, Milan, Italy, and ††Martini Clinic, Prostate Cancer Center Hamburg-Eppendorf, Hamburg, Germany

Maxine Sun and Quoc-Dien Trinh contributed equally to this study.

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OBJECTIVE

• Previous studies showed no survival benefit with respect to performing lymph node dissection (LND) at nephrectomy, whereas a recent population-based analysis suggested otherwise, although the latter relied on imputation. To reconcile the findings of that study by critically evaluating the handling of missing data.

PATIENTS AND METHODS

• Study participants comprised patients diagnosed with non-metastatic renal cell carcinoma (RCC) of all stages who underwent LND at nephrectomy (n = 10 596).

• Multivariable Cox regression models were performed to predict cancer-specific mortality (CSM), where the primary variable of interest was the extent of LND.

• To examine differences in approaches with respect to handling missing data, separate analyses were performed: (i) imputed population; (ii) exclusion of patients with missing data; and (iii) inclusion of patients with missing data as a sub-category.

RESULTS

• Overall, 2916 (28%) patients had missing tumour grade.

• In multivariable analyses, our findings showed that increasing the extent of LND was associated with a significant protective effect on CSM in patients with pN1 after imputation (hazard ratio [HR], 0.82; P = 0.04).

• By contrast, the extent of LND was no longer significantly associated with a lower risk of CSM after excluding patients with a missing tumour grade (HR, 0.83; P = 0.1) or when including patients with missing tumour grade as a sub-category (HR, 0.82; P = 0.05).

CONCLUSIONS

• The findings of the present study failed to corroborate the association of a survival benefit with increasing extent of LND at nephrectomy.

• The different methodologies employed to account for missing data may introduce important biases.

• Such considerations are non-negligible with respect to the interpretation of results for investigators who rely on administrative cohorts.

Video: Metformin for diabetics with NMIBC

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Association of diabetes mellitus and metformin use with oncological outcomes of patients with non-muscle-invasive bladder cancer

Malte Rieken1,3, Evanguelos Xylinas1,4, Luis Kluth1,5, Joseph J. Crivelli1, James Chrystal1, Talia Faison1, Yair Lotan6, Pierre I. Karakiewicz7, Harun Fajkovic10, Marek Babjuk8, Alexandra Kautzky-Willer10, Alexander Bachmann3, Douglas S. Scherr1 and Shahrokh F. Shariat1,2,10

1Department of Urology, 2Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA, 3Department of Urology, University Hospital Basel, Basel, Switzerland, 4Department of Urology Cochin Hospital, APHP, Paris Descartes University, Paris, France, 5Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany, 6Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA, 7Department of Urology, University of Montreal, Montreal, QC, Canada, 8Department of Urology, Hospital Motol, Second Faculty of Medicine, Charles University, Prague, Czech Republic, 9Unit of Gender Medicine, Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria, and 10Department of Urology, Medical University of Vienna, Vienna, Austria

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OBJECTIVE

• To assess the association between diabetes mellitus (DM) and metformin use with prognosis and outcomes of non-muscle-invasive bladder cancer (NMIBC)

PATIENTS AND METHODS

• We retrospectively evaluated 1117 patients with NMIBC treated at four institutions between 1996 and 2007.

• Cox regression models were used to analyse the association of DM and metformin use with disease recurrence, disease progression, cancer-specific mortality and any-cause mortality.

RESULTS

• Of the 1117 patients, 125 (11.1%) had DM and 43 (3.8%) used metformin.

• Within a median (interquartile range) follow-up of 64 (22–106) months, 469 (42.0%) patients experienced disease recurrence, 103 (9.2%) experienced disease progression, 50 (4.5%) died from bladder cancer and 249 (22.3%) died from other causes.

• In multivariable Cox regression analyses, patients with DM who did not take metformin had a greater risk of disease recurrence (hazard ratio [HR]: 1.45, 95% confidence interval [CI] 1.09–1.94, P = 0.01) and progression (HR: 2.38, 95% CI 1.40-4.06, P = 0.001) but not any-cause mortality than patients without DM.

• DM with metformin use was independently associated with a lower risk of disease recurrence (HR: 0.50, 95% CI 0.27–0.94, P = 0.03).

CONCLUSION

• Patients with DM and NMIBC who do not take metformin seem to be at an increased risk of disease recurrence and progression; metformin use seems to exert a protective effect with regard to disease recurrence.

• The mechanisms behind the impact of DM on patients with NMIBC and the potential protective effect of metformin need further elucidation.

Video: How do urology residents rate their laparoscopic experience?

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Training of European urology residents in laparoscopy: results of a pan-European survey

Frederico T.G. Furriel, Maria P. Laguna*, Arnaldo J.C. Figueiredo, Pedro T.C. Nunes and Jens J. Rassweiler†

Department of Urology and Renal Transplantation, University Hospital of Coimbra, Coimbra, Portugal, *Department of Urology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands, and †Department of Urology, Klinikum Heilbronn, University of Heidelberg, Heilbronn, Germany

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OBJECTIVE

• To assess the participation of European urology residents in urological laparoscopy, their training patterns and facilities available in European Urology Departments.

MATERIALS AND METHODS

• A survey, consisting of 23 questions concerning laparoscopic training, was published online as well as distributed on paper, during the Annual European Association of Urology Congress in 2012.

• Exposure to laparoscopic procedures, acquired laparoscopic experience, training patterns, training facilities and motivation were evaluated.

• Data was analysed with descriptive statistics.

RESULTS

• In all, 219 European urology residents answered the survey.

• Conventional laparoscopy was available in 74% of the respondents’ departments, while robotic surgery was available in 17% of the departments.

• Of the respondents, 27% were first surgeons and 43% were assistants in conventional laparoscopic procedures. Only 23% of the residents rated their laparoscopic experience as at least ‘satisfactory’; 32% of the residents did not attend any course or fellowship on laparoscopy.

• Dry laboratory was the most frequent setting for training (33%), although 42% of the respondents did not have access to any type of laparoscopic laboratory.

• The motivation to perform laparoscopy was rated as ‘high’ or ‘very high’ by 77% of the respondents, and 81% considered a post-residency fellowship in laparoscopy.

CONCLUSIONS

• Urological laparoscopy is available in most European training institutions, with residents playing an active role in the procedure. However, most of them consider their laparoscopic experience to be poor.

• Moreover, the availability of training facilities and participation in laparoscopy courses and fellowships are low and should be encouraged.

Video: The two sides of blue light TURBT: better assessment but no lower recurrence rates

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Prospective randomized trial of hexylaminolevulinate photodynamic-assisted transurethral resection of bladder tumour (TURBT) plus single-shot intravesical mitomycin C vs conventional white-light TURBT plus mitomycin C in newly presenting non-muscle-invasive bladder cancer

Timothy O’Brien, Eleanor Ray, Kathryn Chatterton, Muhammad Shamim Khan, Ashish Chandra and Kay Thomas

Urology Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK

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OBJECTIVE

• To determine if photodynamic ‘blue-light’-assisted resection leads to lower recurrence rates in newly presenting non-muscle-invasive bladder cancer (NMIBC).

PATIENTS AND METHODS

• We conducted a prospective randomized trial of hexylaminolevulinate (HAL) photodynamic diagnosis (PDD)-assisted transurethral resection of bladder tumour (TURBT) plus single-shot intravesical mitomycin C vs standard white-light-assisted TURBT plus single-shot intravesical mitomycin C.

• A total of 249 patients with newly presenting suspected NMIBC enrolled at Guy’s Hospital between March 2005 and April 2010. Patients with a history of bladder cancer were excluded.

• The surgery was performed by specialist bladder cancer surgical teams.

• Of the eligible patients, 90% agreed to be randomized.

RESULTS

• Of the 249 patients, 209 (84%) had cancer and in 185 patients (89%) the cancer was diagnosed as NMIBC.

• There were no adverse events related to HAL in any of the patients randomized to the intravesical HAL-PDD arm.

• Single-shot intravesical mitomycin C was administered to 61/97 patients (63%) in the HAL-PDD arm compared with 68/88 patients (77%) in the white-light arm (P = 0.04)

• Intravesical HAL was an effective diagnostic tool for occult carcinoma in situ (CIS). Secondary CIS was identified in 25/97 patients (26%) in the HAL-PDD arm compared with 12/88 patients (14%) in the white-light arm (P = 0.04)

• There was no significant difference in recurrence between the two arms at 3 or 12 months: in the HAL-PDD and the white-light arms recurrence was found in 17/86 and 14/82 patients (20 vs 17%), respectively (P = 0.7) at 3 months, and in 10/63 and 15/67 patients (16 vs 22%), respectively (P = 0.4) at 12 months.

CONCLUSION

• Despite HAL-PDD offering a more accurate diagnostic assessment of a bladder tumour, in this trial we did not show that this led to lower recurrence rates of newly presenting NMIBC compared with the best current standard of care.

Video: Move over fluoroscopy: ultrasound-guided PCNL is just as good

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Percutaneous nephrolithotomy guided solely by ultrasonography: a 5-year study of >700 cases

Song Yan, Fei Xiang and Song Yongsheng

Division of Urology, Sheng Jing Hospital, China Medical University, Shenyang, China

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OBJECTIVE

• To evaluate the safety and efficacy of percutaneous nephrolithotomy (PCNL) solely guided by ultrasonography (US).

PATIENTS AND METHODS

• From May 2007 to July 2012, 705 24-F-tract PCNL procedures were performed (679 patients, of whom 26 had bilateral stones).

• Calyceal puncture and dilatation were performed under US guidance in all cases.

• The procedure was evaluated for access success, length of postoperative hospital stay, complications (modified Clavien system), stone clearance and the need for auxiliary treatments.

RESULTS

• The mean (sd) operating time was 66 (25) min, with a mean (sd) postoperative hospital stay of 3.98 (1.34) days.

• The patients experienced a mean (sd) haemoglobin level decrease of 2.24 (2.02) g/day and the overall stone-free rate at 4 weeks after surgery was 92.6% in patients with a single calculus and 82.9% in patients with staghorn or multiple calculi.

• Auxiliary treatments, including shockwave lithotripsy in 52 patients, re-PCNL in 41 patients and ureteroscopy in 18 patients, were performed 1 week after the primary procedure in 111 (15.7%) cases for residual stones >4 mm in size.

• The sensitivities of intra-operative US-guidance and flexible nephroscopy for detecting significant residual stones and clinically insignificant residual fragments were 95.3 and 89.1%, respectively.

• There were 94 grade 1 (13.3%), 17 grade 2 (2.4%), and two grade 3 (0.3%) complications, but there were no grade 4 or 5 complications.

CONCLUSION

• Total US-guided PCNL is safe and convenient, and may be performed without any major complications and with the advantage of preventing radiation hazards and damage to adjacent organs.

Impact Factor and the BJUI – Vincenzo Ficarra BJUI Associate Editor

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BJUI Associate Editor Vincenzo Ficarra, discusses the BJUI’s aim to increase the quality of papers and the journal’s Impact Factor. The rejection rate shall see an increase from 65% to 80% as a result.

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Laparoscopic and robot-assisted continent urinary diversions

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Video: Double Yang-Monti ileal conduit

Video: Mitrofanoff appendicovesicostomy

Laparoscopic and robot-assisted continent urinary diversions (Mitrofanoff and Yang-Monti conduits) in a consecutive series of 15 adult patients: the Saint Augustin technique

Denis Rey*, Elie Helou*†, Marco Oderda*‡, Jacopo Robbiani*, Laurent Lopez* and Pierre-Thierry Piechaud*

*Department of Urology, Clinique Saint Augustin, Bordeaux, France, †Saint Joseph University, Beirut, Lebanon and ‡Department of Urology, University of Turin, Turin, Italy

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OBJECTIVE

• To present a series of 15 laparoscopic and robot-assisted Mitrofanoff and Yang-Monti vesicostomies in an adult population, and to assess the feasibility and safety of these minimally invasive approaches.

PATIENTS AND METHODS

• Between 2009 and 2012, 15 patients underwent laparoscopic (n = 11) or robot-assisted (n = 4) construction of vesicostomy by a single surgeon (D.R.): Mitrofanoff appendicovesicostomy (n = 11) or double Yang-Monti ileal conduit (n = 4). Fourteen patients underwent concomitant augmentation enterocystoplasty.

• Indications for surgery included neurogenic bladder (n = 11) and urethral dysfunction (n = 4).

• The patients were evaluated postoperatively using cystography. Quality of life (QoL) was evaluated using an internally developed questionnaire.

RESULTS

• All surgeries were successfully completed with no conversions. Operating time was always <5 h. The mean estimated blood loss was 150 mL and the mean follow-up was 22 months.

• Early postoperative complications included deep retrovesical abscess (n = 2) and upper urinary tract infections (n = 4), and one patient had peri-operative cardiac failure.

• Late postoperative complications included stomal stenosis (n = 2), persistent low-pressure bladder incontinence (n = 1) and recurrent infections (n = 1). Surgical excision of the conduit was necessary in one patient.

• Postoperatively, patients showed complete bladder emptying and no leak on follow-up cystography. According to our QoL questionnaire, 13/15 patients did not regret the surgery.

CONCLUSION

• While a longer follow-up is needed to assess the durability of our results, this series shows that the laparoscopic and robot-assisted approaches for the construction of continent urinary diversions are feasible and safe in an adult population.

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